Board Rule 224 - Overview of Delegation

Delegation is an essential nursing skill that RNs use to maximize the nursing care that clients
receive.

Delegation is based upon:

The needs of the patient and the stability of the patient’s condition;

The RN assessment of the potential for patient harm;

The complexity of the task;

The
predictability of the outcomes;

The abilities of the unlicensed assistive personnel (UAP) staff
to whom the task is delegated;

The context of other patient needs to achieve the most
benefit from nursing care since the RN is responsible and accountable for safe and appropriate
delegation (§224.5, RN Accountability for Delegated Tasks), delegation is utilized at the RN’s discretion.

The delegation process is multifaceted. It begins with decisions made at the administrative level of the organization and extends to the staff responsible for delegating, overseeing the process, and performing the responsibilities (NCSBN, 2016). Employers have a responsibility to ensure that practices specified in job descriptions comply with applicable state and federal laws, regulations and credentialing requirements (e.g., Texas Department of State Health Services; Centers for Medicare & Medicaid Services).

The responses to these frequently asked questions (FAQs) are based upon the application of Board of Nursing (BON or Board) Rule Chapter 224 which governs RN delegation in acute care settings or for patients with acute conditions, Chapter 225 which governs RN delegation in independent living environments for clients with stable and predictable conditions, and other relevant BON Rules and Regulations.

Be advised that in many delegation situations other regulations and requirements may apply (§224.11 and §225.15). The Board’s Rule §217.11, Standards of Nursing Practice, requires all licensed nurses (LVNs, RNs, and APRNs) to know and conform to all laws and regulations affecting their area of practice [§217.11 (1)(A)]. In situations where a RN's practice is governed by multiple laws and regulations that include different requirements, the RN must comply with all of them and the most restrictive requirement(s) governs. For example, if one regulation requires an RN to make a supervisory visit to a patient every 14 days and another regulation leaves it to the RN's professional judgment, the RN would have to visit a patient at least every 14 days or more frequently. Although Board staff cannot speak as an expert on other agencies’ regulations and requirements, nurses should become familiar with all applicable requirements for their specific area of practice.

In addition, the BON recognizes that the Texas Medical Board’s (TMB) Rules and Regulations (22 TAC Part 9, Chapters 161-185, 187, 189-200) provide physicians a broad delegatory authority. It is not within the BON’s regulatory purview and beyond the scope of this document to address physician delegation. You may wish to contact the TMB at (512)305-7010, or check their website (www. tmb.state.tx.us) for more information.

Delegation/Assignment

Delegation & Assignment Defined

The use of terms delegate and assign can be confusing and lead to questions regarding the licensure responsibilities associated with the terms. Delegation is defined as “authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is directly assisting a RN by carrying out nursing tasks in the presence of a RN.” [§224.4(3)]...

Registered nurses (RNs) and advanced practice registered nurses (APRNs) are responsible for delegating the right task to the right person in the right set of conditions. Additionally, the education, knowledge, experience, competency, and supervision of the unlicensed person are essential to ensure the delivery of safe nursing care. Because UAP’s do not hold a license that authorizes or governs their practice, the authority to engage in nursing practice must be delegated by a RN.

Assignment is defined as the routine care, activities, and procedures that are within the authorized scope of practice of the RN or LVN or part of the routine functions of the UAP (NCSBN, 2016)Patient safety and the abilities of the person to whom the assignment is being made are important criteria to consider when making an assignment. The assignments that may be made are influenced and guided by the education, knowledge, experience, and physical and emotional abilities of the person to whom assignments are made [§217.11(1)(S)]. Patient safety can be impacted by the complexity or acuity of the patient’s health status and the physical environment in which care is provided.

Advanced Practice Registered Nurses

May an Advanced Practice Registered Nurse (APRN) delegate tasks to other nurses or unlicensed assistive personnel?

Under the RN licensure and role, APRNs may only delegate tasks to unlicensed staff or assistive personnel utilizing the applicable RN Delegation Rules 224 or 225 as appropriate and in compliance with Rule 217.11(3)(B). APRNs are not authorized to exceed the delegation criteria in Rules 224 and 225. While APRNs have collaborative working agreements with physicians, APRNs do not have the same delegatory authority as physicians and therefore are limited to delegation of nursing tasks within the RN licensure and role. The BON's delegation rules (§224 & §225) apply to both RNs and APRNs...

For APRNs, questions arise related to the delegation of medication administration to unlicensed persons when functioning in the clinic setting. The Board’s rules in Chapter 224 (Rule 224.8(c) do not permit the delegation of any medications in the acute care setting (which includes clinics). Likewise, in independent living environments addressed by the Board Rules in Chapter 225, the delegation of injectable medications is not permitted (except for subcutaneous medications prescribed to treat diabetes mellitus). [Board Rule 225.12)]

The APRN's collaborating physician has the ability to delegate medication administration via the Texas Medical Board’s Rule 193. For more information on physician delegation, please see BON PS 15.5 Nurses with Responsibility for Initiating Physician Standing Orders and BON PS 15.11 Delegated Medical Acts. If the physician is the delegating practitioner, but the APRN (or RN) has supervisory responsibilities for the UAP, please see the Board Rules 224.10 (for acute care settings) and/or Board Rule 225.14 (for independent living environments) related to the required supervision of the unlicensed person when tasks have been delegated by non-RN practitioners.

Although the BON does not have regulatory authority over the clinic's operational procedures, it is suggested that documentation in the form of job descriptions, policy and procedure, etc. would provide clear delineations under whose delegated authority the UAP is functioning (i.e., the physician or the APRN.

With regard to other nurses, it is important to note than an APRN may make an assignment to another nurse that takes into account his/her scope of practice and level of licensure [Rule 217.11(1)(S)]. An APRN may not assign tasks to RNs or LVNs that exceed the RN or LVN scope of practice, even if the APRN agrees to co-sign the RN’s or LVN’s documentation. An ARPN’s co-signature for something that is beyond the RN’s or LVN’s scope of practice does not legitimize the RN’s or LVN’s actions. A nurse never functions under the license of another nurse nor does a nurse delegate to another licensed nurse.

Licensed Vocational Nurses

What is the LVN’s scope of practice and role in delegation?

The LVN scope of practice is both directed and supervised [NPA §301.002(2); NPA §301.353; §217.11(2)]. The LVN performs a focused assessment [§217.11(2)]. The delegation decision is based on the comprehensive assessment that is performed by the RN [§217.11(3)]. Since the LVN practice is not autonomous, and the LVN is not educated or licensed to perform a comprehensive assessment, it is beyond the LVN scope of practice to delegate tasks. However, the LVN may assign tasks not requiring delegation and provide supervision to the UAP for assigned tasks...

There is a difference between "delegating" and "assigning" in the BON rules. An assignment is defined as the routine care, activities, and procedures that are within the authorized scope of practice of the RN or LVN or part of the routine functions of the UAP (NCSBN 2016). Both RNs and LVNs must consider patient safety and the abilities of the person to whom the assignment is being made when making an assignment. The assignments that may be made are influenced and guided by the education, knowledge, experience, and physical and emotional abilities of the person to whom assignments are made [§217.11(1)(S)].

The RN is accountable to ensure that nursing care provided by others for whom the RN is professionally responsible is appropriately supervised [217.11(1)(U)]. Although it is beyond the scope of this response to address RN roles and responsibilities in relation to LVNs, the RN's licensure accountability has been met when s/he complies with the above standards while making assignments to LVNs. The LVN is then accountable for the care s/he provides under his/her own license.

Unlicensed Assistive Personnel

RNs may be asked to delegate tasks to UAPs with minimal skill levels or skill sets. Organizations may have policies regarding delegation and delegation duties may be included in RN job descriptions. If an RN refuses to delegate based on the assessment, can the RN be required to delegate?

Delegation is widely viewed as an essential nursing skill the RN uses at their discretion based upon the RN assessment. Since the RN is accountable for the delegation process, the decision to delegate belongs to the RN (Rules §224.5 & §225.5 concerning accountability). However, others (e.g., the client, client's family/significant others, the RN's supervisor, the UAP) may have input that the RN needs to consider in the decision making process. The decision to delegate is based on a thorough working knowledge of BON Rules (§224, §225, and §217 .11) and other relevant regulations. When delegating a task, RNs have a duty to maintain patient safety [Rule 217.11(1)(B)] which supersedes other mandates such as facility policy or physician orders (Position Statement 15.14, Duty of A Nurse in any Practice Setting)...

RNs make delegation decisions that promote client safety utilizing the general criteria for delegation outlined in the BON’s delegation rules [224.6 and 225.9]. See Delegation Flow Charts for additional information on the decision making process.

Employers may have policies governing delegation. Although policies may provide the RN guidance in the delegation process, such policies and job descriptions cannot mandate RN delegation. Policies could, however, put restrictions in place that the RN must follow (e.g., a school district policy does not allow the school RNs to delegate the administration of herbal supplements).

The RN should be well informed when making the decision to delegate. Being informed includes knowledge of applicable regulations, assessment of the client, the task to be delegated, and the competencies of the UAP. Based on this information and professional judgment, the RN will be able to provide rationale(s) for his/her decision to delegate, not to delegate or to exempt from delegation, as applicable.

The rationale for a nurse’s decision to delegate a specific task becomes important if the delegation results in an untoward event or if the RN's inability to utilize UAPs in the care of a client results in the client receiving care in a more restrictive environment. A primary goal when providing care to clients in the independent living environment is to assist the client to achieve the most integrated setting/least restrictive environment throughout the life span. UAPs play a large role in achieving this goal through the completion of tasks that are either delegated to them by a RN or provided under the supervision of the client or client's responsible adult.

Delegation is viewed not only as a management tool for RNs, but in some settings, as a vehicle for care in the least restrictive environment for the client. Given the current nursing shortage and the continued transition of care from acute-care settings to the community setting, there is a growing need for RNs to gain familiarity with delegation and, where applicable, incorporate this principle into the nursing process.

Emergency Medical Technicians/Paramedics

Can an RN delegate nursing tasks to an emergency medical technician (EMT) or paramedic?

The BON's rules in Chapter 224 describe the requirements for RN delegation to unlicensed personnel in an acute care environment such as the emergency department. The BON does not regulate practice settings or facility policies, nor does the Board regulate emergency medical technicians or paramedics. Whether certified or licensed, the BON views the EMT or paramedic role within the acute care, inpatient setting or emergency department setting to be equivalent with the UAP for the purposes of RN delegation. While EMTs and paramedics do have out-of-hospital training and licensure/certification applicable to the out-of-hospital setting, within the acute care environment the scope of practice of the EMT or paramedic is limited to the role of the UAP...

Each RN decides on a case-by-case basis what nursing tasks may be delegated in accordance with the applicable delegation rules. It should be noted that job descriptions developed by employing institutions cannot mandate RN delegation, nor can an RN be forced to delegate by facility policy or physician order. Further, BON delegation rules clarify that it is not delegation when the UAP is directly assisting a RN by carrying out nursing activities in the presence of a RN.

The RN retains responsibility for delegating tasks that are reasonable and prudent. The RN should be able to explain his/her critical thinking and rationale for the delegation decision. There may be instances in which a physician or other provider directly delegates to the EMT or paramedic. The BON delegation rules address the RN who may be supervising an unlicensed person to whom the non-RN practitioners has delegated tasks (§224.10). The RN always has a responsibility to protect client safety [§217.11 (1)(B)]; therefore, the RN still has a duty to intervene if s/he sees something being done incorrectly by the unlicensed person, and to notify the ordering practitioner of the incident.

Family Members

Patients' families may assist in patient care. When instructing family members in providing care, is this considered delegation?

RNs may be involved in patient/family teaching and this is not delegation. The RN is responsible for providing complete and accurate instructions and oversight, in addition to client assessment (§ 224.6(1) and 225.5(a)). However, the requirements of the rules in Chapters 224 & 225 typically do not apply in this context. Further, the BON defines UAPs as individuals who are "monetarily compensated" to provide health care services. Since families and significant others are not usually compensated for providing care to their loved one, this is not a delegation situation.

Nursing Students

Many organizations use nursing students (i.e., individuals who are employed in the organization and are currently students in an accredited school of nursing).

Is it an acceptable practice for nursing students who provide documented didactic education and demonstration of competence from their nursing program, to perform such duties as urinary catheter placement, sterile dressing changes, and venipuncture in acute care settings?

May they perform patient assessments and independently document these assessments in acute care settings?

Employers may hire nursing students to work as UAPs in positions such as aides or nursing assistants. This is a different situation than nursing students who are completing their clinical course work requirements in a facility and are monitored by nursing school faculty. In that scenario, students are authorized to perform nursing tasks as a part of their academic program; therefore, RN delegation is not required. However, nursing students who are employed by a facility as UAPs must function under the delegated authority of a RN to perform nursing tasks [see Rule 224.4(4)(C)...

It is important to understand that although these individuals may have gained competency in many nursing skills through their academic preparation, they are unlicensed and the BON's delegation rules apply. The delegating RN is required to consider these acquired skills as this may impact the RN's decision to delegate certain discretionary tasks.

Rule 224.8, Delegation of Tasks, discusses most commonly delegated tasks; discretionary tasks; and tasks prohibited from delegation. Nursing tasks such as urinary catheter placement, sterile dressing changes, and venipuncture fall under the category of discretionary tasks. Thus a RN must meet additional criteria (in addition to general criteria in Rule 224.6) in order to delegate these more complicated, invasive procedures. The tasks that may not be delegated in acute care settings or to clients with acute conditions include medication administration, nursing assessments, formulation of the nursing care plan, evaluation of the client's response to the care rendered, and specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention.

Documentation

When a RN delegates a task to a UAP, is that UAP responsible for documenting the care provided or is the RN responsible? Does the RN have to co-sign this documentation?

Responsibilities regarding documentation and co-signature are not specified in the delegation rule but may be addressed in facility policies and procedures. The RN's responsibility for complete and accurate documentation is delineated in the Standards of Nursing Practice [BON Rule §217.11 (1)(D)]. As determined by the employing agency/facility with nursing collaboration, UAPs might play a role in the documentation of care they provide. Co-signature indicates that the RN was present or observed all the activities that the UAP is reporting in the record. Without this presence or observation, the BON does not recommend that a RN co-sign others' documentation.

Supervision

What is the RN's/APRN’s responsibility when s/he supervises an unlicensed assistive person who has been delegated tasks by a physician or other non-RN practitioners?

Board rules §224.10 and §225.14 address situations where the RN is supervising a UAP, yet that RN is not the delegating practitioner because another licensed practitioner is delegating to this UAP. The Documentation Supervision delegation rules allow this practice since delegation, as addressed by BON rule, is not restricted by employment relationships. That is, it is permissible by BON rule for a treating physician or a RN from one employing agency (e.g., a home health agency) to delegate to a UAP from a different agency (e.g., an assisted living facility)...

Board’s rules §224.10 and §225.14 clarify that the supervising RN's licensure liability is met when the RN:

Verifies the training of the unlicensed person;

Verifies that the unlicensed person can properly and adequately perform the delegated task without jeopardizing the client's welfare;

Adequately supervises the unlicensed person.

Since the supervising RN has a nurse-client relationship, s/he has a duty to maintain patient safety [§217.11(1)(B)]. That is, the supervising RN is obligated to intervene if s/he sees something being done incorrectly by the UAP and to notify the delegating practitioner of the incident. Further, if the supervising RN cannot verify the UAP's competency to perform the delegated task, the supervising RN must communicate this fact to the delegating practitioner.

What if a RN from a different agency/facility delegates to the UAP under my supervision? May a RN delegate to a UAP from another agency with which he/she do not have supervisory authority?

In a scenario where the delegating RN and the UAP are not employed by the same agency/facility challenges may exist; the RN has a responsibility to know and comply with Board Rules §224 and §225 and recognize unique challenges. That is, when the delegating RN and the UAP are not employed by the same agency, RN responsibilities such as verifying competency via personnel records and providing adequate supervision are more difficult to perform. It is advantageous for all interested parties to determine what is legally required and to delineate roles and responsibilities to arrive at a collaborative agreement in the best interest of the client.

When a nursing task has been delegated to a UAP by a RN, what constitutes adequate supervision? How accessible should the RN be to the UAP? How frequently should the RN make supervisory visits on the UAP?

Supervision requirements are addressed in Board Rules §224.7 and §225.9. Supervision may be provided in person or via telecommunications. The BON delegation rules identify that the RN who is delegating has the responsibility for determining the degree of supervision necessary and to develop a plan for adequate supervision. This plan is based on the analysis of such factors as: (1) the stability of the client's status in relation to the delegated task; (2) the training, experience, and capability of the UAP; (3) the nature of the delegated task; and (4) the proximity and availability of the RN to the UAP when the nursing task will be performed.

The BON does not issue specific guidelines for frequency of supervisory visits [with the exception of delegation of insulin administration under Rule 225.12 (5) or required RN proximity to the UAP and client. The BON provides general parameters and relies on the RN's professional judgment to determine the appropriate level of nursing involvement and oversight. If there are other legal standards, for example, standards issued by rule and/or statute from another state or federal agency, then the RN is required to adhere to those standards in addition to the Nursing Practice Act and Board’s rules (Rule 217.11(1)(A)).

A facility/agency could implement a system to assist the RN in meeting supervision needs via telecommunications and/or supervision by other RNs or LVNs. However, the delegating RN retains accountability for this process since s/he is accountable for the tasks delegated to the unlicensed persons.

Physician Orders

In what circumstances is a physician order required for nursing delegation?

Since RN delegation is defined as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task, the BON does not require RNs to obtain physician orders for RN delegation nor can a physician force an RN to delegate. The RN is accountable for the delegation process, therefore the decision to delegate belongs to the RN (Rules §224.5 & §225.5 pertaining to accountability). However, others (i.e., the physician, the client, client's family/significant others, the RN's supervisor, the UAP) may have input into the decision making process. The decision to delegate is based on a thorough working knowledge of BON Rules (§224, §225, and §217.11) and other relevant regulations.

Procedures/Treatments

Yes, a RN may delegate finger sticks for blood glucose monitoring [§224.8(a)(2)(A) and §225.10(4)(A)]. In Board Rule §225.12, Delegation of Insulin or Other Injectable Medications Prescribed in the Treatment of Diabetes Mellitus, blood glucose monitoring [§225.12(2)] is an important component of this delegated task...

Can ventilator care, oral suctioning, and tracheal suctioning be delegated in the independent living environment?

In an independent living environment for clients with stable and predictable conditions, Board Rule §225.10(7) allows the RN to delegate "ventilator care or tracheal care; including instilling normal saline and suctioning of a tracheostomy with routine supplemental oxygen administration." The assessment criteria specified in §225.6 and delegation criteria specified in §225.9 must be met in order for the RN to delegate this task and this task may not be exempted from delegation. If after the RN’s assessment, the RN determines that the task requires professional nursing judgement in the client's situation, then the RN shall not delegate the task.

The rules in Chapters 224 and 225 do not specifically mention oral suctioning. The rules are not intended to provide lists of specific tasks that may or may not be delegated; rather the rules identify categories of tasks that may or may not be considered for delegation. The RN uses his/her professional judgment to determine if a task under consideration is safe to delegate given the uniqueness of the client's situation. Under Chapter 224 which governs delegation for clients with acute conditions or in acute care settings, this task would be classified as a discretionary task [§224.8(b)(2)(C)] which may be delegated, provided additional criteria are met. In the independent living environment the RN may justify delegating oral suctioning by noting that oral suctioning may be delegated under Chapter 224 and the more complicated task of tracheal suctioning may also be delegated. It is also possible that upon assessment the RN may determine that oral suctioning can be designated as a health maintenance activity exempted from delegation for a client with a stable and predictable condition residing in an independent living environment.

CPAP and BiPAP Procedures

Can an RN delegate a CPAP or BiPAP procedure to a UAP in the independent living environment?

The BON is aware that in independent living environments the use of NIV has increased for the treatment of numerous chronic respiratory disorders, such as chronic obstructive pulmonary disease, asthma, sleep apnea and cystic fibrosis. In order for clients to achieve optimal health benefits in the least restrictive environment as possible, RNs may use the delegation process in collaboration with the client or the client's responsible adult (CRA) to decide if NIV procedures are safe to delegate in home settings.

In January of 2012, the Texas Board of Nursing (BON) approved noninvasive ventilation (NIV), such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) therapy as additional tasks that RNs may determine are safe and appropriate to delegate in accordance with Chapter 225, RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions. The tasks RNs may decide to delegate are listed in Rule 225.10. Rule 225.10 (13) now permits RNs to delegate NIV procedures to unlicensed personnel and further, Rule 225.10 (14) permits delegation of tasks that the RN may reasonably conclude as safe to delegate based on an assessment consistent with §225.6.

RNs are responsible for adequately and accurately assessing the needs of clients in order to ensure their safety in these settings. The delegation process can assist RNs in making decisions as to how unlicensed personnel will be utilized to accomplish safe and effective supportive services and care.

Medication Administration

Can UAPs administer immunizations?

The laws regarding immunizations are not within the BON’s authority. With regard to vaccines of any kind, an Attorney General opinion in 1981 (MW-318) determined immunizations are preventative, thus no medical diagnosis is required or made when a person receives an immunization.

Board Rule 225 - Applicability

In relation to delegation, what types of clients and settings should a RN refer to Chapter 225?
In relation to delegation, what types of clients and settings should a RN refer to Chapter 225?

There are three criteria that must be met in order for a Registered Nurse to apply the delegation rules from Chapter 225. The criteria is 1) the client is in an independent living environment such as a home a group home, foster home, assisted living facility or school; (2) the client, if 16 or older, or client's responsible adult is willing and able to participate in decisions about the overall management of the client's health care; and (3) the task is for a stable, predictable condition as defined by §225.4. [Board Rule 225.1(a)]

Should a client develop an acute condition (become unstable or unpredictable) the delegation rules from Chapter 224 Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments (clinic, physician office or hospital) would be applicable. At times such as these, the RN may be using both delegation chapters.
The delegation rules in Chapter 225 may still apply for those conditions that the client may have that are stable and predictable. However, while using 224 to provide oversight and delegation of tasks for the acute condition, the RN may continue to utilize 225 for the oversight and delegation of tasks for the client’s ongoing stable and predictable conditions.

Client's Responsible Adult

Who is eligible to serve as the "client's responsible adult" (CRA)? Is it possible for the CRA and the unlicensed assistive person (UAP) to be the same person? Can the CRA be an employee of the facility/agency providing the services?

BON Rule 225.4(5) defines CRA as “an individual, 18 or older, normally chosen by the client, who is willing and able to participate in decisions about the overall management of the client's health care and to fulfill any other responsibilities required under this chapter for care of the client. The term includes but is not limited to parent, foster parent, family member, significant other, or legal guardian.”...

The term is broadly defined in order for the role of CRA to be filled by an individual meeting the rule criteria and mutually agreed upon by the delegating RN, the CRA, and the client, where applicable. The Board relies on the professional judgment of the nurse to ensure that the relationship between individuals serving as a CRA is appropriate. Keep in mind that the CRA's role is to serve as an advocate for the client by performing such duties as monitoring activities performed by the UAP, evaluating the client's response to the care provided, serving as a point of contact to make healthcare decisions and/or providing guidance to the UAP. When delegation occurs in the independent living environment where the client's condition is stable and predictable, the need for the client's or CRA's involvement is crucial since continual nursing services (e.g., assessment and evaluation) are not required in this context. As a result, there is frequently minimal nursing oversight provided and if the client is unable to participate in his/her own care then another individual must act on the client's behalf.

Placing the responsibility of serving as both the CRA and the UAP for one individual may present a precarious situation. Further, there may be more than one UAP attending to the client. It is not the intent of the rule language to address situations where the client has multiple CRAs (e.g., the CRA changes with each UAP that reports for duty) or frequently changing CRAs (e.g., high UAP turnover). However, systems may be put into effect where, for instance, the client has a substitute CRA when the permanent CRA is unavailable.

The broad parameters of the CRA definition also allow situations where the CRA can be, for instance, the client's trust officer or an employee of the facility/agency providing the services. As the client's advocate, the CRA has an ethical duty to make the client's needs a top priority.

In conclusion, although the CRA definition is written in generic terms allowing the rule language to adapt to a variety of client situations, the BON relies on the professional judgement of the RN to determine, in collaboration with other involved parties, who is appropriate to serve as the CRA in an effort to utilize UAP services in accomplishing client goals.

Delegation under the BON Rules in Chapter 225 requires the involvement of the client or the client's responsible adult (CRA). What if the CRA moves out of town and the client is unable to participate in the overall management of his health care?

The precepts of Chapter 225 do not mandate that the CRA be immediately accessible in person. In some situations, it is acceptable to have the CRA accessible via telecommunications. Under section §225.6 RN Assessment of the Client, the RN obtains information on a variety of contributing factors to make a determination if the care can be delegated, exempted from delegation or should not be delegated. Several of these factors relate to the CRA's participation in the client's care. The intent is RN evaluation of each factor to note if strengths in one area (e.g., a strong support system and/or the client's condition is very stable and predictable) can compensate for weaknesses in another area (e.g., CRA is in another town but is readily accessible by phone). The RN must reassess when there are changes in the client condition or contributing factors to determine if delegation is still appropriate.

Health Maintenance Activities

RNs in independent living environments such as, home and community-based settings or school health while caring for clients with stable and predictable conditions must utilize the rules in Chapter 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions when making decisions that pertain to delegation...

Depending on the assessment of the client and the delegation criteria, the RN may decide to: designate a task a HMA that does not require delegation; delegate a task to an unlicensed person; or have a nurse perform the task. HMAs are defined as "tasks that enable the client to remain in an independent living environment and that go beyond activities of daily living (ADLs) because of the higher skill level required to perform," [See Board Rule 225.4(8)]a. The Board believes that expanding the list of HMAs will foster a client's independence and further supports a client or the client's responsible adult (CRA) who is able to train and supervise unlicensed personnel in the performance of a HMA, thus enabling the client to remain in the least restrictive environment as possible. For a complete list of tasks that can be designated as HMAs please refer to Board Rule 225.4(8) (A-K).

Because all nurses are required to promote a safe environment for their clients and others [See Board Rule 217.11(1)(B)], the RN must always consider what is safest for the client when making decisions to designate a task a HMA that does not require delegation. Nurses are reminded to document their decisions concerning delegation in the client's record. For additional information on delegation, see the Texas Board of Nursing Delegation Resource Packet.

Medication Administration

Is drawing up a required dose of insulin a delegated task?

According to Rule §225.12, the RN may delegate administration of insulin or other injectable medications prescribed in the treatment of diabetes mellitus subcutaneously, nasally or via an insulin pump. As part of the medication administration process, the UAP may be required to draw up the insulin or other injectable medications utilizing a sliding scale to determine the required dose of insulin or medication. These are generally permissible tasks and should be specified in the RN's instructions and physician's order. The RN may not delegate these activities if s/he will have to make decisions that require professional nursing or medical judgment. The calculation of insulin doses may not be delegated. The BON does not consider the application of a sliding scale to be of the same complexity of calculating a dose based on carbohydrate-to-insulin ratios.

Can the administration of medications that have to be crushed be delegated?

Yes, assuming that the medication to be administered is from a properly labeled container, can safely be crushed and is based upon RN instructions/physician orders. It is incumbent upon the RN to instruct the UAP on the appropriate skill of crushing the medication and the documentation of the medication administration.

Can SQ medications other than insulin, i.e. allergy shots or heparin, be delegated in an independent living environment?

No, the administration of medications by an injectable route, except for subcutaneous insulin or other injectable medications prescribed in the treatment of diabetes mellitus, may not be delegated in accordance with Rule §225.13(5).

Can RNs delegate the initial dose of medications to UAPs in the independent living environment?

Board Rule 225.13(5)(E) states that the RN shall not delegate “the administration of the initial dose of a medication that has not been previously administered to the client unless the RN documents in the client's medical record the rationale for authorizing the unlicensed person to administer the initial dose.” Therefore, the RN is cautioned that it is not normally within the scope of sound professional nursing judgment to delegate initial dose medications. This is because there is much uncertainty regarding the client's response (e.g., allergic reaction) to a medication that s/he has never in his/her lifetime taken before. However, the BON recognizes there are situations where it may be safe to delegate initial dose medications and if a RN chooses to do so, s/he must provide a rationale for her/his decision to delegate. Rationales should be based on such factors as supportive assessment findings, BON Rule §217.11 and current nursing/health-related literature.

Can RNs delegate PRN or "as needed" medication administration to a UAP in the independent living environment?

Board Rule Chapter 225 does not specifically prohibit the delegation of medications administered on a PRN basis; however, several factors have to be considered. First and foremost, is nursing judgment required in order to determine when to administer the medication? Does the client require nursing assessment to evaluate the effectiveness of the medication? If so, this is a task that cannot be delegated.

There are many situations where it is quite safe for the UAP to administer a PRN medication. An example of this is an adult client with quadriplegia who is knowledgeable about his/her own health care and is able to direct the UAP, but is unable to self-administer his/her PRN medication due to lack of fine-motor movement in his/her hands.

An example of an inappropriate decision would be to delegate administration of PRN pain medication to a UAP caring for a 2-year-old client since evaluating pain in a toddler can be a complex task requiring nursing judgment.

Can a UAP participate in refilling a client’s prescription?

The delegation rules do not prohibit a UAP from calling in refills for a client. In the definition of "assistance with self-administered medication" under section §225.4 (3), the term includes "assisting in reordering medication from a pharmacy." The rationale for this language is that the pharmacy has received the original order from the physician either telephonically, electronically, or by a written prescription. The original pill container/bottle must clearly indicate the number of refills that are permitted. In addition, there must be mechanisms to ensure appropriate communication between the client/significant other/CRA, the RN, and the UAP. There must also be appropriate documentation in the client record/MAR regarding current medications, therapeutic response, and communication with the RN.

There are several requirements located in the Nursing Practice Act and Board Rules and Regulations that will serve as a check and balance, if properly executed by the RN, to ensure that the client is monitored appropriately and that medications are administered in accordance with the physician orders. It remains the responsibility of the RN to assess the nursing needs of the client, to develop a plan of nursing actions, to implement those actions, and to evaluate client responses.

If there is any indication that a problem has been identified with prescriptions, client response to medication, or competency of unlicensed personnel, the RN is accountable for intervening in an appropriate manner, regardless of the health care setting. If any of the criteria in Chapter 225.9 are not met, it would be inappropriate for the RN to delegate tasks. It seems reasonable that a UAP could assist the client in the independent living environment with a phone call to request a refill or making a trip to the pharmacy on behalf of the client as long as the pharmacy had the original order and the original pill container/bottle was clearly marked indicating that a specific number of refills had been authorized by the ordering practitioner.

Medication or Procedures in an Emergency Situation

Are there any medications or procedures that may be delegated in an emergency situation in independent living environments such as in home health or school health?

Planning for emergencies in independent living environments requires the RN to utilize both Chapter 224, Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments and Chapter 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions...

With the increased complexity of the school practice setting, it is not always feasible for a RN to be physically present on campus when a student emergency occurs. However, the RN is often the most qualified professional to make care decisions or support those personnel who are physically present until emergency personnel arrive as appropriate. RNs must use their nursing judgement to decide to delegate life-sustaining medications and treatments to unlicensed personnel in independent living environments such as community-based settings, client homes, or schools.

While all the delegation criteria are important in Board Rule 224.6, the RN must take into consideration how the supervisory standards will be met as delegation decisions are made. The RN is required to provide adequate supervision while an unlicensed person is performing a task, particularly in emergency situations. The RN must consider his or her geographical distance and the time it takes to reach a client that is experiencing an emergency in order to direct unlicensed personnel when to notify the Emergency Medical System (EMS). RNs are also responsible for timely follow-up, which may include a face-to-face assessment depending on the emergency situation and the RN's location to the individual. Delegation decisions and instructions to unlicensed personnel should be documented in the client's record.

Hospice

Is a client receiving hospice care considered stable & predictable?

Yes, according to Rule §225.4(11). Stable and predictable is defined as “a situation where the client's clinical and behavioral status is determined to be non-fluctuating and consistent. A stable/predictable condition involves long term health care needs which are not recuperative in nature and do not require the regularly scheduled presence of a registered nurse or licensed vocational nurse. Excluded by this definition are situations where the client's clinical and behavioral status is expected to change rapidly or in need of the continuous/continual assessment and evaluation of a registered nurse or licensed vocational nurse. The condition of clients receiving hospice care in an independent living environment where deterioration is predictable shall be deemed to be stable and predictable.”

Delegation for the School Nurse

Can RNs delegate medication administration via envelopes or sealed plastic bags and give it to the teacher or another UAP when s/he accompanies students on field trips?

According to Board Rule 225.11(1), a RN may delegate the administration of medications from a daily reminder pill container. This rule section also applies to RNs who delegate medication administration to UAPs in the school setting when there is from a properly labeled unit dosage container filled by a registered nurse or another qualified district employee...

Thus, the RN may prepare unit dose medications in a separate container for the designated UAP to administer. There are training requirements stipulated in the rule and it is strongly advised that the RN label the medication including such information as the name of the medication, student's name, dose, time to be administered, and route and adverse effects which may be associated with the medication. Although it is beyond the purview of the BON, Texas Education Code, Chapter 22, Section 22.052 grants immunity from liability to school district employees, as long as current district policy is followed, have a signed parental consent form and the medication appears to be in the original container or single dose container.

Is the RN responsible for the principal’s assignment of medication administration in the school setting?

Even though a UAP may administer medications as requested by the principal, this law does not relieve the RN of his/her obligations under the Nursing Practice Act and the BON's rules for supervision (Board Rule 225.14). Further, TEC, Chapter 21, Section 21.003(b) requires that school health services be provided by a licensed health care professional or someone acting under their delegated authority. If a Texas school district hires an employee to provide school nursing services, that employee must be licensed as a nurse by the Texas Board of Nursing.

Should there be a situation where the principal assigns medication administration to an unlicensed school employee and a RN provides nursing services at the school, the RN still has a duty to the student. In the school setting, the BON views the students as the RN's clients and based on his/her licensure, the RN owes a "duty" to his/her client. Board Rule 217.11, Standards of Nursing Practice, define the RN's duty to his/her client and BON Position Statement 15.13, Role of the LVNs and RNs in School Health,
provides further clarification. Specific to instances of principal assignment, this position statement reads:

the administration of medication may be assigned to an unlicensed person by the public school official in accordance with the rules of the Texas Education Code. The RN's obligation under 22 TAC §225.14 is to (1) verify the training of the unlicensed person, and (2) verify the competency of the unlicensed person to perform the task safely. If the RN is unable to assure (1) and (2) have been met, the RN must (b) notify the public school official of the situation.

This situation is closely related to instances of physician delegation where the RN supervises the UAP.

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